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Winning the Fight against Infant Mortality in Regions IV & VI Michael C. Lu, MD, MPH Chair Secretary’s Advisory Committee on Infant Mortality Regions IV.

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Presentation on theme: "Winning the Fight against Infant Mortality in Regions IV & VI Michael C. Lu, MD, MPH Chair Secretary’s Advisory Committee on Infant Mortality Regions IV."— Presentation transcript:

1 Winning the Fight against Infant Mortality in Regions IV & VI Michael C. Lu, MD, MPH Chair Secretary’s Advisory Committee on Infant Mortality Regions IV & VI Infant Mortality Summit New Orleans, LA January 12-13

2 E Pluribus Unum

3 Infant mortality rates, selected countries, 2005 Source: Health, United States, 2008

4 Infant mortality rates, United States, 2007 An infant death occurs within the first year of life. Source: National Center for Health Statistics, final mortality data, and period linked birth/infant death data, 1995-present. Retrieved January 10, 2012, from

5 Infant mortality rates, United States, 2007 Source: CDC/NCHS linked birth/infant death data set, 2007.

6 Racial Gap in Infant Mortality Data Source: NCHS

7 We Can Do Better

8 Richmond-Kotelchuck Model Knowledge Base Political Will Social Strategy

9 Richmond-Kotelchuck Model Knowledge Base Political Will Social Strategy

10 Major Pathways to Spontaneous Preterm Birth  Premature Activation of Maternal-Fetal HPA Axis (Stress)  Infection/Inflammation  Uteroplacental ischemia or thromboses  Uterine overdistension

11 Components of preterm birth Spontaneous preterm labor 40-45% Source: Goldenberg et al. Lancet, 2008.

12 Spiral Arteries (non-pregnant)

13 Spiral Artery (pregnant)

14 Spiral Artery (Preterm)

15 Life Course Perspective

16 Life Course Perspective Lu MC, Halfon N. Racial and ethnic disparities in birth outcomes: a life-course perspective. Matern Child Health J. 2003;7:13-30.

17 Richmond-Kotelchuck Model Knowledge Base Political Will Social Strategy

18 SACIM Priorities

19 SACIM Members Mark Bartel, M. Div, BCC Sharon M. Chesna, M.P.A. Robert Mande Corwin, M.D., FAAP Raymond L. Cox, Jr., M.D., M.B.A. Phyllis Armelle Dennery, M.D. Tyan A. Parker Dominguez, Ph.D., M.P.H., M.S.W. Carolyn L. Gegor, C.N.M., M.S., F.A.C.N.M. Arden Handler, Dr. P.H., M.P.H. Fleda Mask Jackson, Ph.D., M.S. Kay A. Johnson, M.P.H., Ed. M., B.A. Miriam Harriet Labbok, M.D., M.P.H. Michael C. Lu, M.D., M.S., M.P.H. Joanne B. Martin, Dr.P.H., R.N., FAAN Monica Mayer, M.D. Joann R. Petrini, Ph.D., M.P.H. Virginia Morriss Pressler, M.D., M.B.A., FACS Melinda Dolan Sanders, M.S.N., R.N. Ruth Ann Shepherd, M.D., FAAP Susan E. Sheridan, M.I.M., M.B.A. Sara G. Shields, M.D., M.S. Adewale Troutman, M.D., M.P.H., M.A., CPH David S. de la Cruz, Ph.D., M.P.H. (staff)

20 1. Quality & Safety

21 Quality and Safety Support improvement in the quality and safety of maternity, newborn & infant care Elective delivery at < 39 weeks 17P (17 alpha-hydroxyprogesterone caproate) Smoking cessation Assisted Reproductive Technologies

22 Intermountain Healthcare Oshiro BT, Henry E, Wilson J, Branch DW, Varner MW; Women and Newborn Clinical Integration Program. Decreasing elective deliveries before 39 weeks of gestation in an integrated health care system. Obstet Gynecol Apr;113(4):

23 Ohio Perinatal Quality Collaborative Donovan EF, Lannon C, Bailit J, Rose B, Iams JD, Byczkowski T; Ohio Perinatal Quality Collaborative Writing Committee. A statewide initiative to reduce inappropriate scheduled births at 36(0/7)-38(6/7) weeks' gestation.Am J Obstet Gynecol Mar;202(3):243.e1-8.

24 Perinatal Regionalization Figure 5. Meta-analysis Results of Adequate- and High-Quality Publications on Very Preterm Infants Figure 4. Meta-analysis Results of Adequate- and High-Quality Publications on Extremely Low-Birth-Weight Infants Lasswell SM, Barfield WD, Rochat RW, Blackmon L. Perinatal regionalization for very low-birth-weight and very preterm infants: a meta-analysis. JAMA Sep 1;304(9):

25 2. Preconception & Interconception Care

26 CDC/ATSDR Select Panel’s Recommendations to Improve Preconception Health and Health Care in the U.S.  Recommendation 1. Individual responsibility across the life span. Each woman, man and couple should be encouraged to have a reproductive life plan.  Recommendation 2. Consumer awareness. Increase public awareness of the importance of preconception health behaviors and preconception care services by using information and tools appropriate across various ages; literacy, including health literacy; and cultural/linguistic contexts.  Recommendation 3. Preventive visits. As a part of primary care visits, provide risk assessment and educational and health promotion counseling to all women of childbearing age to reduce reproductive risks and improve pregnancy outcomes.  Recommendation 4. Interventions for identified risks. Increase the proportion of women who receive interventions as follow-up to preconception risk screening, focusing on high priority interventions (i.e. those with evidence of effectiveness and greatest potential impact).  Recommendation 5. Interconception care. Use the interconception period to provide additional intensive interventions to women who have had a previous pregnancy that ended in an adverse outcome (i.e., infant death, fetal loss, birth defects, low birthweight, or preterm birth).  Recommendation 6. Prepregnancy checkup. Offer, as a component of maternity care, one prepregnancy visit for couples and persons planning pregnancy.  Recommendation 7. Health insurance coverage for women with low incomes. Increase public and private health insurance coverage for women with low incomes to improve access to preventive women’s health and preconception and interconception care.  Recommendation 8. Public health programs and strategies. Integrate components of preconception health into existing local public health and related programs, including emphasis on interconception interventions for women with previous adverse outcomes.  Recommendation 9. Research. Increase the evidence base and promote the use of the evidence to improve preconception health.  Recommendation 10. Monitoring improvements. Maximize public health surveillance and related research mechanisms to monitor preconception health. Johnson K, Posner SF, Biermann J, Cordero JF, Atrash HK, Parker CS, Boulet S, Curtis MG; CDC/ATSDR Preconception Care Work Group; Select Panel on Preconception Care.Johnson K, Posner SF, Biermann J, Cordero JF, Atrash HK, Parker CS, Boulet S, Curtis MG; CDC/ATSDR Preconception Care Work Group; Select Panel on Preconception Care. Recommendations to improve preconception health and health care--United States. A report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care. MMWR Recomm Rep Apr 21;55(RR-6):1-23.

27 Preconception & Interconception Care IOM Clinical Preventive Services for Women Contraceptive services Lactation support HIV testing HPV testing STI tesing Interpersonal and domestic violence screening Gestational diabetes screening Well-woman preventive care visit including pre- and interconception care

28 3. Medicaid Innovations

29 What Can Medicaid Do to Improve Perinatal Outcomes? Single largest payer of perinatal healthcare in U.S. Pays for > 40% of all births Spends $39 billion a year on perinatal healthcare $21 billion for pregnancy and delivery $18 billion for newborn care Andrews RM. The national hospital bill: The most expensive conditions by payer, Healthcare Cost and Utilization Project. Statistical brief #59. September 2008

30 Medicaid Innovations New York Denial of payment for elective delivery < 39 wks Texas Denial of payment for elective delivery < 39 wks Minnesota Require providers to submit information on nature of labor & delivery incl induction before payment is made Washington Reducing payment for uncomplicated cesarean Incenting hospitals & providers to engage in QI activities to reduce elective delivery < 39 wks & NSTV cesarean North Carolina Incentive payments for meeting target outcomes (e.g. postpartum visit, 17P, elective delivery < 39 wks, NTSV Cesarean) Ohio Mandate state-wide reporting of perinatal quality measures

31 Medicaid Innovations North Carolina’s Pregnancy Medical Homes Use payment innovations to drive quality improvement & systems integration Projected cost-savings to Medicaid

32 4. Title V & MCH Programs

33 Title V and MCH Programs Improve design & impact of MCH programs e.g. Healthy Start as agent of change for service coordination, systems integration, and community transformation

34 5. Healthcare Reform & Financing

35 Healthcare Reform & Financing Support implementation of the Affordable Care Act Access Content and quality Organization & Delivery Community health centers expansion Centers for Medicare and Medicaid Innovations Public health & prevention investments Maternal, Infant, and Early Childhood Home Visiting Programs

36 Healthcare Reform & Financing The Committee is deeply concerned about spending cuts to vital programs that may drive up infant mortality

37 Perinatal Outcomes Childhood Diseases Adult Diseases

38 Developmental Origins of Health & Disease

39 6. Health Equity

40 Health Equity The Committee urges a broad-based approach that addresses both clinical factors and social determinants using a life-course approach

41 Health Development Educational Development Community Development Economic Development Best Babies Zone

42 Rural Health and Infant Mortality Need a rural strategy on infant mortality Workforce development Access to healthcare facilities Mental and behavioral issues Social determinants

43 Data & Research

44 Data and Research Need a national research agenda on causes and prevention of disparities in maternal and infant mortality Improve population surveillance of maternal & infant mortality Need for data capacities and data support

45 Richmond-Kotelchuck Model Knowledge Base Political Will Social Strategy

46 Collaborative Innovations

47 The definition of insanity is doing the same thing over and over and expecting different results Benjamin Franklin

48 We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable rightsm, that among these are Life, Liberty, and the Pursuit of Happiness. Declaration of Independence

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